Prevalence, risk factors, and genetic diversity of Bartonella henselae infections in pet cats in four regions of the United States.

Blood was collected from a convenience sample of 271 pet cats aged 3 months to 2 years (mean age, 8 months, median and mode, 6 months) between May 1997 and September 1998 in four areas of the United States (southern California, Florida, metropolitan Chicago, and metropolitan Washington, D.C.). Sixty-five (24%) cats had Bartonella henselae bacteremia, and 138 (51%) cats were seropositive for B. henselae. Regional prevalences for bacteremia and seropositivity were highest in Florida (33% and 67%, respectively) and California (28% and 62%, respectively) and lowest in the Washington, D.C. (12% and 28%, respectively) and Chicago (6% and 12%, respectively) areas. No cats bacteremic with B. clarridgeiae were found. The 16S rRNA type was determined for 49 B. henselae isolates. Fourteen of 49 cats (28.6%) were infected with 16S rRNA type I, 32 (65.3%) with 16S rRNA type II, and three (6.1%) were coinfected with 16S rRNA types I and II. Flea infestation was a significant risk factor for B. henselae bacteremia (odds ratio = 2.82, 95% confidence interval, 1.1 to 7.3). Cats >or=13 months old were significantly less likely to be bacteremic than cats

Identification of a p28 gene in Ehrlichia ewingii: evaluation of gene for use as a target for a species-specific PCR diagnostic assay.

PCR was used to amplify a 537-bp region of an Ehrlichia ewingii gene encoding a homologue of the 28-kDa major antigenic protein (P28) of Ehrlichia chaffeensis. The E. ewingii p28 gene homologue was amplified from DNA extracted from whole blood obtained from four humans and one canine with confirmed cases of infection. Sequencing of the PCR products (505 bp) revealed a partial gene with homology to outer membrane protein genes from Ehrlichia and Cowdria spp.: p30 of Ehrlichia canis (< or =71.3%), p28 of E. chaffeensis (< or =68.3%), and map1 of Cowdria ruminantium (67.3%). The peptide sequence of the E. ewingii partial gene product was deduced (168 amino acids) and the antigenicity profile was analyzed, revealing a hydrophilic protein with < or =69.1% identity to P28 of E. chaffeensis, < or =67.3% identity to P30 of E. canis, and < or =63.1% identity to MAP1 of C. ruminantium. Primers were selected from the E. ewingii p28 sequence and used to develop a species-specific PCR diagnostic assay. The p28 PCR assay amplified the expected 215-bp product from DNA that was extracted from EDTA-treated blood from each of the confirmed E. ewingii infections that were available. The assay did not produce PCR products with DNA extracted from E. chaffeensis-, E. canis-, or E. phagocytophila-infected samples, confirming the specificity of the p28 assay for E. ewingii. The sensitivity of the E. ewingii-specific PCR assay was evaluated and determined to detect as few as 38 copies of the p28 gene.

Infections with Ehrlichia chaffeensis and Ehrlichia ewingii in persons coinfected with human immunodeficiency virus.

The clinical course and laboratory evaluation of 21 patients coinfected with human immunodeficiency virus (HIV) and Ehrlichia chaffeensis or Ehrlichia ewingii are reviewed and summarized, including 13 cases of ehrlichiosis caused by E. chaffeensis, 4 caused by E. ewingii, and 4 caused by either E. chaffeensis or E. ewingii. Twenty patients were male, and the median CD4(+) T lymphocyte count was 137 cells/microL. Exposures to infecting ticks were linked to recreational pursuits, occupations, and peridomestic activities. For 8 patients, a diagnosis of ehrlichiosis was not considered until > or =4 days after presentation. Severe manifestations occurred more frequently among patients infected with E. chaffeensis than they did among patients infected with E. ewingii, and all 6 deaths were caused by E. chaffeensis. Ehrlichiosis may be a life-threatening illness in HIV-infected persons, and the influence of multiple factors, including recent changes in the epidemiology and medical management of HIV infection, may increase the frequency with which ehrlichioses occur in this patient cohort.

Outcomes of an antimicrobial control program in a teaching hospital.

The clinical outcomes and cost-effectiveness of an antimicrobial control program (ACP) were studied. The impact of an ACP in a teaching hospital was analyzed by comparing clinical outcomes and intravenous antimicrobial costs over two two-year periods, the two years before the program and the first two years after the program's inception. Admission baseline data, length of stay, mortality, and readmission rates were gathered for each patient. Patients were identified by using the International Classification of Diseases. Multivariate logistic regression models were constructed for mortality and for lengths of stay of 12 or more days. The acquisition costs of intravenous antimicrobial agents for the second baseline year and the entire program period were tabulated and compared. The average daily inpatient census was determined. The ACP was associated with a 2.4-day decrease in length of stay and a reduction in mortality from 8.28% to 6.61%. Rates of readmission for infection within 30 days of discharge remained about the same. Inpatient pharmacy costs other than intravenous antimicrobials decreased an average of only 5.7% over the two program years, but the acquisition cost of intravenous antimicrobials for both program years yielded a total cost saving of $291,885, a reduction of 30.8%. The institution's average daily census fell 19% between the second baseline year and the second program year. An ACP directed by a clinical pharmacist trained in infectious diseases was associated with improvements in inpatient length of stay and mortality. The ACP decreased intravenous antimicrobial costs and facilitated the approval process for restricted and nonformulary antimicrobial agents.

Management protocol for abacavir-related hypersensitivity reaction.

OBJECTIVE: To develop an abacavir hypersensitivity reaction management protocol for the University of Oklahoma Health Sciences Center. DATA SYNTHESIS: Conference abstracts, published literature, and manufacturer-provided materials were reviewed to define the syndrome and manifestations and to recommend steps to take when a patient develops abacavir-related reactions. RESULTS: Initial education, formalized contact and response mechanism, and intervention levels were incorporated into a protocol for clinicians. CONCLUSIONS: Abacavir, a newly approved agent for the treatment of HIV, has been associated with a fatal hypersensitivity reaction. Our protocol provides a mechanism to minimize progression of abacavir hypersensitivity reaction by providing a formalized management procedure.

Evidence of reproductive failure and lack of perinatal transmission of Bartonella henselae in experimentally infected cats.

Five female specific pathogen-free (SPF) cats inoculated intradermally with B. henselae and bacteremic for 4 weeks, and one cat inoculated with 0.9% NaCl, were bred with uninfected SPF male cats. The uninfected female became pregnant with one breeding, while three infected cats became pregnant 1-12 weeks later, after repeated breedings. Two infected females either did not become pregnant or maintain pregnancies despite repeated breedings. Infected cats produced anti-B. henselae IgM and IgG antibodies. Fetuses and kittens of infected cats were not infected and did not produce anti-B. henselae antibodies. Male cats bred with infected females did not become infected or seroconvert. Maternal anti-B. henselae IgG antibodies detected in sera of kittens 2 weeks post-partum were no longer detectable 10 weeks post-partum. These findings suggest that B. henselae causes reproductive failure in female cats, but is not transmitted transplacentally, in colostrum or milk, or venereally. Infected cats immunosuppressed with methylprednisolone acetate after their kittens were weaned had no detectable bacteria in tissues, suggesting that they were no longer infected.

Cat scratch disease: the rare role of Afipia felis.

Since its isolation in 1988, Afipia felis has been associated with cat scratch disease (CSD) in only one report and its role in CSD has been questioned. We have cultured A. felis from a lymph node of a patient with CSD. 16S rRNA gene sequencing, DNA relatedness studies, fatty acid analysis, and PCR of the A. felis ferredoxin gene showed that the isolate is identical to the previously reported A. felis isolate. To determine the role of A. felis in CSD, PCR of the 16S rRNA gene followed by hybridizations with specific probes were performed with lymph node specimens from CSD patients. All 32 specimens tested positive for Bartonella henselae and negative for A. felis. We conclude that A. felis is a rare cause of CSD. Diagnostic tests not conducive to the identification of A. felis might cause the diagnosis of CSD due to A. felis to be missed.

Activity of the soft gelatin formulation of saquinavir in combination therapy in antiretroviral-naive patients. NV15355 Study Team.

OBJECTIVE: A Phase II, open-label, randomized, parallel-arm, multicentre trial to compare the antiviral activity and safety of two formulations of saquinavir (SQV), soft gelatin (SQV-SGC) and hard gelatin (SQV-HGC) capsules, in combination with two nucleoside reverse transcriptase inhibitors (NRTI), in antiretroviral-naive, HIV-1-infected individuals. PARTICIPANTS: A total of 171 people of > or = 13 years, with plasma HIV-1 RNA levels > or = 5000 copies/ml, who had received no protease inhibitor therapy, < or = 4 weeks NRTI therapy and no antiretroviral treatment within 28 days of screening. Eighty-one people were randomized to the SQV-HGC group and 90 to the SQV-SGC group. A total of 148 patients completed 16 weeks of therapy. INTERVENTION: Therapy for 16 weeks with either SQV-SGC 1200 mg or SQV-HGC 600 mg, both three times a day, in combination with two NRTI. RESULTS: Using an on-treatment analysis, patients taking SQV-SGC had a larger reduction in plasma HIV-1 RNA than those taking SQV-HGC (-2.0 versus -1.6 log10 copies/ml). Eighty per cent of those on SQV-SGC had < 400 copies HIV RNA/ml, compared with 43% in the SQV-HGC group (P = 0.001). A statistically significant difference in the area under the curve (AUC) values between the SQV-SGC and SQV-HGC arms (-1.7 versus -1.5 log10 copies/ml, respectively; P = 0.0054) was observed when withdrawals prior to week 12, major protocol violators and patients with < 75% compliance were excluded from the analysis; however, the difference between the values for the intent-to-treat population was not significant (P = 0.1929). Adverse events (mostly mild) included diarrhoea and nausea. CONCLUSIONS: SQV-SGC was generally well tolerated and gave significantly more potent suppression of plasma HIV-1 RNA in antiretroviral-naive patients than SQVHGC.

Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease.

OBJECTIVE: To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN: Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING: Large military medical center and its referring clinics. PATIENTS: Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION: Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES: Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS: Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS: Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.

Culture-negative endocarditis caused by Bartonella henselae.

A 4-year-old girl presented with clinical evidence of infective endocarditis involving her aortic valve, but blood cultures were sterile. Serologic studies and analysis of resected valve by immunohistochemistry and polymerase chain reaction established the diagnosis of Bartonella henselae endocarditis. Clinicians should be aware that B. henselae can cause apparent culture-negative endocarditis in children.

Paranasal sinus infection due to atypical mycobacteria in two patients with AIDS.

Atypical mycobacteria, which are common opportunistic pathogens in patients with AIDS, have not been previously implicated in the pathogenesis of paranasal sinus infections; we describe two such patients. Clinical and radiographic evidence of bilateral maxillary and ethmoid sinusitis was observed for one patient; his infection proved resistant to therapy with conventional antimicrobials and decongestants. Endoscopic ethmoid sinus biopsy yielded a specimen containing acid-fast bacilli (AFB) that were later identified as Mycobacterium kansasii. Antimycobacterial therapy had not resulted in amelioration of the sinusitis > 2 months later, at which time he died of cerebral toxoplasmosis. The second patient presented with a tender right frontotemporal soft-tissue mass; a computed tomogram disclosed that it extended through the frontal bone to the frontal sinus. Inflamed tissue debrided from the sinus contained AFB; cultures first yielded M. kansasii and later Mycobacterium avium complex. Bacteremia due to both organisms was also demonstrated. Infection progressed despite therapy.

Rhodococcus equi infections of humans. 12 cases and a review of the literature.

Increased recognition of Rhodococcus equi as a human pathogen has occurred since 1983, when the first review article summarized the world's literature of 12 cases. In this article, we present 12 cases from the University of Oklahoma Health Sciences Center and review 60 from the literature. Most cases occur in immunocompromised hosts and present as chronic cavitary pneumonias. Associated extrapulmonary disease is seen at diagnosis in 7% of patients with pneumonia, and relapse occurs at extrapulmonary sites in 13%, often without reappearance of pulmonary disease. Relapse may follow a course of antimicrobial therapy that is too brief, but can also occur during treatment. Infections also occur in the gastrointestinal tract, causing enteritis and regional adenitis with abscesses. Contaminated wounds may become infected. Isolated bacteremias may be a manifestation of latent infection recurring during a period of immune suppression. A common feature of human R. equi infection is delay in diagnosis. The insidious course of disease contributes to delay, as does failure to identify the organism. R. equi is easily cultured on nonselective media but commonly mistaken for a diphtheroid or occasionally for a mycobacterium based on acid-fast appearance. Form and duration of treatment are closely related to host immune status. Immunocompromised patients require prolonged or indefinite therapy with multiple antibiotics. Infections in immunocompetent hosts are easily treated with short courses of single agents. Infections related to contaminated wounds are treated primarily by irrigation and debridement. Infections in immunocompromised hosts are increasing in frequency largely due the AIDS epidemic. Infections in immunocompetent hosts, reported rarely before this series, may be underdiagnosed, perhaps because R. equi resembles common commensals and has limited virulence in this population. This report demonstrates that R. equi infections, including community-acquired pneumonias, occur in immunocompetent hosts.

Morphologically variable bacilli of cat scratch disease are identified by immunocytochemical labeling with antibodies to Rochalimaea henselae.

The identification of the causative organisms of cat scratch disease (CSD) has been elusive. The demonstration of Warthin-Starry stain-positive pleomorphic bacilli in lymph nodes of patients with CSD and recent serologic and epidemiologic data suggest an etiologic role of Rochalimaea henselae in CSD. The authors studied lymph node biopsy specimens of 46 patients with illnesses clinically consistent with CSD and found pleomorphic bacilli in 15 (33%). The organisms were labeled by polyclonal rabbit antibodies induced by outer surface proteins of R henselae. This finding further supports the possibility of an important role of R henselae in the pathogenesis of CSD.

Rochalimaea henselae infection in acquired immunodeficiency syndrome causing inflammatory disease without angiomatosis or peliosis. Demonstration by immunocytochemistry and corroboration by DNA amplification.

Rochalimaea henselae causes bacillary angiomatosis, bacillary peliosis, and persistent bacteremia. Difficult to cultivate, it is detectable in infected tissues by immunocytochemistry. This technique demonstrated R henselae in autopsy specimens obtained from three deceased patients who had acquired immunodeficiency syndrome, with pathologic tissue changes lacking neoangiogenic features. From the first patient, the cause of nodular collections of lymphocytes and nonepithelioid histiocytes in the liver, spleen, lymph nodes, bone marrow, and heart eluded detection until immunocytochemical identification of R henselae. In the second case, unexpected gross and microscopic necroinflammatory nodules in the liver and spleen contained Warthin-Starry-staining bacilli identified as R henselae immunocytochemically. The third patient was found to have pathologic changes in his liver and spleen comparable with those of the second case, as well as several other disseminated infections. In two cases, identification of R henselae was corroborated through sequencing polymerase chain reaction-amplified bacterial DNA recovered from tissue; in one case, DNA could not be amplified, possibly because of postmortem degradation. Application of the immunocytochemical technique thus has expanded the recognized spectrum of histopathologic findings associated with R henselae infection in acquired immunodeficiency syndrome, as well as proving to be potentially more sensitive than DNA amplification for this purpose when applied to autopsy tissues.

Bacteremia due to Rochalimaea henselae in a child: practical identification of isolates in the clinical laboratory.

Two closely related species of Rochalimaea, Rochalimaea quintana and Rochalimaea henselae, are nutritionally fastidious but can be cultivated on bacteriologic media from the blood of patients with diverse clinical presentations. We report a case of culture-proven R. henselae bacteremia in a child with persistent fever. Serologic evidence of infection by R. henselae was ascertained by testing sera at two intervals for immunoglobulin G or immunoglobulin M antibodies by enzyme immunoassay and immunoblot. The case isolate and a collection of other strains (R. henselae, R. quintana, and related organisms) were used to test commercial identification systems for their comparative utility in the identification of Rochalimaea spp. on a practical basis. Of six systems designed for testing of either fastidious or anaerobic isolates of bacteria, the MicroScan Rapid Anaerobe Panel was the only system that distinguished R. henselae from R. quintana. Four of five others gave reactions that were unique within their data bases but did not distinguish Rochalimaea isolates at the species level.

Polymerase chain reaction-based restriction fragment length polymorphism analysis of a fragment of the ribosomal operon from Rochalimaea species for subtyping.

Restriction endonuclease analysis of a polymerase chain reaction-amplified DNA fragment which included the spacer region between the genes coding for 16S and 23S rRNAs and a portion of the gene coding for 23S rRNA (spacer + 23S) was done on 10 previously characterized clinical isolates of Rochalimaea henselae, one clinical isolate of Rochalimaea quintana, and the type strains of R. henselae, R. quintana, Rochalimaea vinsonii, and Bartonella bacilliformis. Brucella abortus DNA was not amplified by the primer set used. The clinical isolates of Rochalimaea were obtained from blood or tissue from patients with and without preexisting disease. The amplicon from each strain was digested with five endonucleases (AluI, HaeIII, TaqI, HinfI, and MseI). AluI and HaeIII were useful in species differentiation and subtyping of R. henselae. R. henselae isolates showed six different restriction patterns with AluI and four patterns with HaeIII. TaqI, HinfI, and MseI were useful only in species differentiation. These observations indicate that PCR amplification of the spacer + 23S region of the ribosomal DNA of Rochalimaea spp., along with restriction endonuclease analysis, allows differentiation of Rochalimaea spp. from closely related genera, differentiation among the species within Rochalimaea, and differentiation of strains within R. henselae. The subtyping potential of this method may be useful for further clinical and epidemiologic studies of the spectrum of diseases caused by R. henselae.

Clinical experience with HIV-infected patients at the University of Oklahoma Health Sciences Center: an update.

We reviewed the course of 545 human immunodeficiency virus (HIV)-infected patients seen between 1983 and March 30, 1991. A majority were Caucasian homosexual or bisexual men, while parenteral drug abusers represented a smaller proportion than seen nationwide. In the 274 patients with the acquired immunodeficiency syndrome (AIDS), the distribution of AIDS-defining conditions was generally consistent with those reported in studies from elsewhere in the United States. However, toxoplasmosis remained relatively uncommon. There was a slightly higher incidence of disseminated histoplasmosis compared to other studies. HIV encephalopathy (AIDS dementia) was likely underdiagnosed. Although data suggested prolongation of the asymptomatic phase of HIV infection, median survival after AIDS diagnosis remained approximately 12 months.

Dual organism infection in biopsy specimens from immunocompromised patients: two cases demonstrated by immunocytochemistry.

We report two cases in which immunocytochemistry demonstrated simultaneous infections within a single biopsy specimen obtained from each of two immunocompromised patients in whom multiple organism infection was not suspected. Using a rapid immunocytochemical technique, Pneumocystis carinii and Cryptococcus neoformans were demonstrated in a transbronchial lung biopsy from the first patient; Candida and cytomegalovirus were demonstrated in an endoscopic biopsy of the esophagus from the second patient. Routine hematoxylin and eosin as well as special stains failed to establish the presence of more than one infectious agent in either case. Mycology cultures ultimately confirmed the presence of Cryptococcus in the first case, but cultures were not performed in the second case due to the scant amount of tissue obtained from the biopsy. The results indicate that concurrent infection by more than one opportunistic organism in immunocompromised patients can easily remain unrecognized. The use of immunocytochemistry may thus provide an important adjunct to routine and special stains or specific cultures.

Polypoid endobronchial lesions. A manifestation of bacillary angiomatosis.

Polypoid endobronchial lesions occurred in a patient with acquired immunodeficiency syndrome (AIDS) with recent fever, skin lesions, lymphadenopathy, lung infiltrates, and pleural effusions. His condition improved with antimicrobials and vincristine. After therapy ceased, skin lesions recurred and gastroesophageal mucosal lesions developed. Bacillary angiomatosis was identified during retrospective analysis of skin and endobronchial biopsy specimens.